A nurse is providing discharge teaching to a client who is taking risperidone. Which of the following instructions should the nurse include in the teaching?

"This medication may increase your blood pressure."

"Flu-like symptoms are an expected adverse effect of this medication."

"Avoid becoming overheated while taking this medication."

"Muscle twitches can occur the first few weeks while taking this medication."

Answer and Explanation

The Correct Answer is C

A. "This medication may increase your blood pressure."

This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.

B. "Flu-like symptoms are an expected adverse effect of this medication."

This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.

C. "Avoid becoming overheated while taking this medication."

This statement is correct. Risperidone, like many other antipsychotic medications, can interfere with the body's ability to regulate temperature. This can lead to an increased risk of overheating, especially in hot weather or during vigorous physical activity. Therefore, it's important for patients taking risperidone to be cautious and avoid becoming overheated, as this could potentially lead to heat-related complications.

D. "Muscle twitches can occur the first few weeks while taking this medication."

This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.

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Correct Answer is C

Explanation

While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.

B) "Your doctor is a man, so it seems like this should not be a problem."

Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.

C) "I can review the assignments and arrange for a female nurse to care for you."

Explanation:

Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.

D) "The nurse assigned to care for you is very capable and cares for other women in this situation."

While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.

A. "Are you thinking of harming yourself?" B. "Do you really think your family would be better off without you?" C. "When did you first start feeling this way?" D. "Tell me what is happening right now."

Correct Answer is A

Explanation

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

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A nurse is providing discharge teaching to a client who is taking risperidone. Which of the following instructions should the nurse include in the teaching?

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Correct Answer is C

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